Diabetic Retinopathy

Diabetic Retinopathy

Dr. Devin Prabhakar MS, DNB, MNAMS, FRCS
Divya Prabha Eye Hospital, Trivandrum 695011
+91471-2442050, drdevin@gmail.com

Objectives
By the end of the session participants will
be able to:
• Define & classify diabetic retinopathy
• List signs and symptoms of diabetic
retinopathy
• State why signs & symptoms occur
• When referral to an ophthalmologist is
required.
• Treatment options available
drdevin@gmail.com www.DivyaPrabha.in

Diabetic Eye Diseases
• Diabetic Retinopathy
• Cataract
• Glaucoma
• Refractive errors
• Stye


When Does Retinopathy Arise

Prevalence of DR
• At diagnosis 20%
• 10 years after diagnosis 40-50%
• 20 years after diagnosis
– Type I 100%
– Type II 60%


With strict control of DM:
• Risk of developing retinopathy was
reduced by 75%
• Reduction in the rate of progression of
retinopathy in existing retinopathy 50%
• Diabetes Control and Complications Trial
Research Group N Engl J Med 1993;
329:977-986.


Microaneurysm

• Small protuberances on the retinal blood
vessels. The first sign of eye damage.
Microaneurysms are reversible if the blood
glucose control is improved

Hard Exudates
• Yellow spots seen in the
retinaThey are lipid
break-down products
that are left behind
after localized edema
resolves. You can kind
of think of them like the
dirt-ring that gets left
behind after the
bathwater drains out.

IRMA
• Intraretinal microvascular abnormalities
(lRMA) : Dilated, tortous retinal
capillaries that act as a shunt between
arterioles and venules. frequently seen
adjacent to areas of capillary closure.
IRMA may resemble focal areas of flat
NVE . But in IRMA : intraretinal location.
absence of profuse leakage on fluorescein
angiography. failure to cross over major
retinal blood vessels. www.DivyaPrabha.in
drdevin@gmail.com

• A) cotton-wool
spot
• B) venous
beading
• C) intraretinal
microvascular
abnormalities;
• D) intraretinal
hemorrhages.


NVD
• New Vessels: Unlike IRMA, they arise on
the retinal surface and may extend or be
pulled into the vitreous cavity.
• NVD : NV appears on or within one DD of
disc margin .
• NVE : any other location .


• Fibrous Glial
proliferation :
Accompained
growth of new
vessels. It is
proliferation
between the
posterior
vitreous gel and
the ILM. Derived
from retinal
glial cells and
drdevin@gmail.com fibrocytes.
www.DivyaPrabha.in

Oph. Invest. of dr
• Fundus Photography
• Fluorescein Angiography
– Guide treatment of CSME to identify
Ischemic maculopathy
– IRMA vs NV evaluation
• Optical Coherence Tomography
• USG – B scan


FFA


OCT
• Optical Coherence Tomography OCT
creates cross section of retina. It
demonstrates 3 basic structural changes
of the retina from diabetic macular
edema (DME), that is, retinal swelling,
cystoid edema, and serous retinal
detachment


Risk Factors for dr
• Duration of diabetes : is the most
important factor.
• In patients diagnosed as having diabetes
before the age of 30 years, the incidence
of DR :
• after 10 years is 50%
• after 30 years is 90%


RISK FACTORS for dr
• Age at diagnosis of diabetes
• Duration
• Poor control of diabetes
• Pregnancy
• Hypertension
• Nephropathy
• Hyperlipidemia
• Obesity
• Anemia
• Smoking
• Cataract surgery


Stages of Retinopathy

• No DR • No Macular Edema
• Mild NPDR • Macular Edema
• Mod NPDR Present
• Severe NPDR
• PDR


Macular edema types
• Focal ME :which has
identifiable leakage
source.
• Cystoid ME : in which
fluid accumulate in OPL
and INL to form cystoid
spaces.
• Diffuse ME : which has
multiple unidentifiable
source of leakage.

CSME (ETDRS):definition
• retinal thickening 500
from fovea
• HE within 500 microns
from fovea with
thickening
• 1500 of thickening with
any part within 1 DD of
fovea


DME: Pathophysiology
• DME is the result of microvascular
changes in diabetes leading to
incompetence of vessels
• Hypoxic state stimulate VEGF causing
more CME


DME: Morbidity
• DME is the leading cause of new blindness
in the US .
• Untreated , 25-30 % of CSME double their
visual angle within 3 years
• Treated the risk drops by 50%


Differential Diagnoses of dr
• ARMD
• Exudative BRVO
• CRVO
• Hypertension
• Macular Edema
• Irvine-Gass Uveitis


Treatment Modalities
LASER Photocoagulation
CSME – Focal & Grid PDR–
Pan Retinal Photocoagulation
INTRA VITREAL
anti VEGF – Bevacizumab, Ranibizumab
steroids – Triamcinolone acetonide
PARS PLANA VITRECTOMY


Focal/grid laser
• Significant visual improvement is uncommon.
Photocoagulation reduced the risk of moderate
visual loss from diabetic macular edema by 50%,
from 24% to 12%, 3 years after initiation of
treatment.
• Laser treatment is most effective when initiated
before visual acuity is lost. Laser treatment of
diabetic macular edema should precede panretinal
photocoagulation (PRP) by at least 6 weeks because
PRP before has been known to worsen diabetic
macular edema. PRP should not be delayed in
patients with very severe nonproliferative diabetic
retinopathy or high-risk proliferative diabetic
retinopathy


Deferral of focal laser
• Hypertension or fluid retention associated with
heart failure, renal failure, pregnancy, or any
other causes that may aggravate macular edema.
• when the center of the macula is not involved,
visual acuity is excellent, and the patient
understands the risks
• Treatment of lesions close to the foveal avascular
zone may result in damage to central vision and
with time laser scars may expand and cause
further vision deterioration.


Intravitreal triamcinolone
acetonide
IVTA has been shown to significantly reduce
macular edema and to improve visual
acuity, particularly. Action is maximal at 1
week, lasting 3-6 months. Patients should be
counseled about the risk (30-40%) of
increased intraocular pressure, of which
virtually all can be medically controlled.
Other adverse effects include a less than 1%
chance of retinal detachment, cataract, and
endophthalmitis


Rx Intravitreal anti-VEGF
agents
• Ocular VEGF increases retinal vascular
permeability, causes breakdown of the
blood-retina barrier, and results in retina
edema. VEGF is up-regulated in diabetic
retinopathy. Three currently available
anti-VEGF agents are pegaptanib sodium,
ranibizumab, and bevacizumab


CSME: Conclusion
• Untreated, 25-30% of patients with CSME
exhibit a doubling of the visual angle
within 3 years. Treated, the risk drops by
50%.


Ocular Risk Factors Removal of
cataract
• DR may progress after cataract surgery.
Patient who have CSME, SNPDR or PDR
should undergo photocoagulation if the
media is sufficiently clear.
• If the cataract preclude retina evaluation
and treatment, prompt postoperative
retinal evaluation and treatment should
considered


Follow up of dr
• Annually Normal
• Every 9 months Mild NPDR
• Every 6 months Moderate NPDR
• Every 6 months CSME
• Every 4 months Sever NPDR
• Every 2- 4 months CSME
• Every 2-3 months PDR


Panretinal photocoagulation
• The benefit of early panretinal photocoagulation
at the severe nonproliferative or worse stage of
retinopathy is greater in patients with type 2
diabetes than in those with type 1.
• Other factors, such as poor compliance with
follow-up, impending cataract extraction or
pregnancy, and status of fellow eye will help in
determining the timing of the panretinal
photocoagulation.
• It is preferable to perform the focal
photocoagulation first, prior to panretinal
photocoagulation to prevent laser-induced
exacerbation of the macular edema


DCCT 1993

• 1441 subjects with IDDM followed for 6.5
years. Randomized into strict and
conventional treatment. Strict control
group had average hbA1c 7.2%
Conventional 8.8%
• Strict control resulted in reduction of
retinopathy by 76%
• Reduced risk of progression by 54%


Glycemic Control
• Total lifetime exposure to glycemia
was the principal determinant of the risk
of retinopathy
• There is no level ofglycemic control
below which a reduction in risk does not
occur. Improved control always reduced
risk of retinopathy retinmopathy


Role of BP
• Hypertension is an independsant risk
factor for DR and its progression.
• UKPDS 1998:
– Tighter control of BP resulted in 34%
reduction in progression of DR.
– 47% reduced risk of loss 3 lines VA


Role of cholesterol
• WESDR 19914: Higher serum cholesterol
increased risk of HE in type I
• ETDRS 1996: Higher serum lipids
increased risk of HE and loss of VA
• Elevated lipids may increase the
morbidity of diabetic macular edema.


Pregnancy : DR
DR accelerate during pregnancy and
improve postpartum. Do not hesitate
to treat with laser when indicated.
FFA should be avoided in all but the
most difficult cases of macular
edema.


Quiz #1 True of False
• People with diabetes are more likely than
people without diabetes to develop
certain eye diseases

True


#2 True or False
• Diabetes eye diseases has early warning
signs

• FALSE


#3 True or False
• People with diabetes should have yearly
eye examinations

• TRUE


#4 True or False
• Diabetic retinopathy is caused by changes
in the blood vessels in the eye.

• TRUE. In some people, blood vessels in
the retina may swell and leak fluid. In
other people, abnormal new blood
vessels grow on the surface of the
retina.


#5 True or False
• People with diabetes are at low risk for
developing glaucoma.

• FALSE


#6 True or False
• Laser surgery can be used to halt the
progression of diabetes retinopathy

• TRUE. In laser surgery, laser light is used
to shrink the abnormal vessels or seal
leaking blood vessels. Laser surgery has
been proven to reduce the 5 year risk of
vision loss from advanced retinopathy by
more than 90%

#7 True or False
• People with diabetes should have regular
eye examination through dilated pupils.

• TRUE


#8 True or False
• Cataract are common among people with
diabetes.

• TRUE


#9 True or False
• People who have good control of their
diabetes are not at high risk for diabetic
eye disease.
• FALSE. Even with good control of blood
glucose, there is still a risk of developing
diabetic eye disease. However studies
have shown that careful management of
blood sugar levels slows the onset and
progression of diabetic retinopathy.

#10 True or False
• The risk of blindness from diabetic eye
disease can be reduced.

• TRUE. With early detection and timely
treatment, the risk of blindness from
diabetic eye disease can be reduced.


“We choose our joys and
sorrows long before we experience
them.”
― Kahlil Gibran

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Diabetic Retinopathy

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